Chapter 44: Pain and Pain Management Flashcards
What are the challenges of pain management?
- nurse cannot see or feel patient’s pain
- purely subjective; no two can experience the same pain
Pain is defined by the International Association of the Study of Pain as
an unpleasant, common subjective sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
Pain
is whatever the experiencing person says it is, existing whenever he/she says it.
Physiology of Pain
- transduction
- transmission
- perception
- modulation
transduction
- converts energy produced by thermal chemical or mechanical stimuli into electrical energy.
- the pain producing stimulus starts at the periphery and travel across sensory periphery nerve fibers (nocireceptors) causing action potential leading to transmission.
transmission
- cellular damage caused by stimuli resulting in release of excitatory neurotransmitters.
- the transmitters surround the pain fibers and spread the pain message to cause inflammatory response
perception
painful stimuli then travels through transmission to the cerebral cortex to be processed in the brain and the person becomes aware of the pain.
modulation
- once the brain perceives the pain, release of inhibitory neurotransmitters help to produce analgesic effect.
- last phase of pain impulse
Gate-Control Theory of Pain
- gating mechanisms located along the CNS regulate or block pain impulses.
- pain impulses pass through when the gate is open and are blocked when the gate is closed.
closing the gate is the basis for
non-pharmacological pain relief: pain threshold (the point at which person feels pain)
Responses to Pain
- physiological responses
2. behavioral responses
physiological responses
when pain causes fight-or-flight response resulting in stimulation of sympathetic and parasympathetic nervous system
behavioral responses
influenced by person’s culture, experiences, and perceptions of pain
Acute pain
warns people of injury and disease; protective
Characteristics of acute pain
- identifiable cause
- short in duration
- limited tissue damage
- self-limiting
- lasts less than 6 months
Chronic pain
- non protective and serves no purpose.
- episodic pain, cancer pain, idiopathic pain
Characteristics of chronic pain
- prolonged pain
- varies in intensity
- lasts longer than 6 months
Common Misconceptions about Pain
the following statements are false:
- Patients who cannot speak do not feel pain
- Patients who abuse substances overreact to pain
- Patients with minor health conditions feel less pain compared to those with severe physical alternation
- Chronic pain is psychological
- Patients who are in a hospital experience pain
Factors Influencing Pain: Physiological Factors
- Age
- Fatigue
- Genes
- Neurological Function
Factors Influencing Pain: Social Factors
- Attention
- Previous Experience
- Family and Social Support
- Spiritual Factors
Factors Influencing Pain: Psychological Factors
Anxiety and Coping Style
Factors Influencing Pain: Cultural Factors
how patients cope with pain based on what is expected and accepted by their culture
Assessment of Pain
- Determine the patient’s perspective of pain
- Obtain the pts description of pain
- Utilize pain scales that are valid and reliable
- Review Potential factors affecting pts pain
- Identify medical comorbidities
- Pts own perspective of pain
Determine the patient’s perspective of pain
include hx of pain, what it means, how it affects the pt emotionally, physically and socially
Obtain the patient’s description of pain
characteristics of pain
Utilize pain scales that are valid and reliable
make them specific to patient population
Identify medical comorbidities
diabetes, cancer, hypertension, thyroid issues…
Patient’s Own Perspective of Pain
- be sensitive to patients level of pain: determine what level will allow the pt to function.
- if pain is acute and severe, it is unlikely that a pt is able to describe their pain in detail: assess for location, severity and quality; wait for the moment when the pt feels better for more detailed pain assessment (PQRST)
PQRST
- Palliative or Provocative Factors
- Quality
- Region (location)
- Severity
- Timing
-Effect
Timing
Onset, Duration and Pattern
Location of Pain
- superficial or cutaneous
- deep or visceral
- referred
- radiating
Severity
use appropriate pain scale: numerical rating scale (rates pain from 0-10); verbal descriptor scale (six word descriptors from no pain to unbearable pain), faces pain scale (cartoon faces ranging from 0-6)
Quality
tell me what the discomfort feels like
Aggravating and Precipitating Factors
describe what activities make the pain worse
Relief Measures
describe what activities make it better
Effects of Pain on the Patient
- behavioral effects
- influence on ADLs
- concomitant symptoms
behavioral effects
assess for vocal response, facial and body movements, and social interaction
influence on ADLs
assess for the ability to participate in routine activities
concomitant symptoms
assess for coexisting symptoms adding to pts pain
Nursing Diagnosis for Pain
- accurate only after a complete pain assessment
- results of complete data and collection analysis
- reveals presence of existing or potential pain
Examples of Nursing Diagnosis RT Pain
- Activity Intolerance
- Impaired Physical Mobility
- Impaired Social Interaction
- Dressing Self-Care Deficit
- Ineffective Coping
- Anxiety
Pain Management Planning
- Determine goals and outcomes
- Choose interventions for pain relief
- Prioritize interventions according to patient’s level of pain
- Educate the patient and family on pain and pain management when appropriate
- Collaborate with other health care team members
Implementation
requires an individualized approach
- try the least invasive or safest therapy first along with what worked for the patient previously.
- use strategies to minimize patient pain through caring behaviors
Implementation and Health promotion
- maintaining wellness
- non-pharmacological pain relief interventions
maintaining wellness
have the patients actively participate in their own wellbeing
Non-pharmacological pain relief interventions
can be used alone or w/ pharmacological interventions (cognitive-behavioral pain interventions, physical pain relief interventions)
Non-pharmacological pain interventions are useful for patients who
- cannot tolerate pain medications
- wish to reduce multiple medication administration
- seek alternative methods
Pharmacological interventions have a higher priority in ______ compared to non-pharmacological.
acute pain
Examples of non-pharmacological pain interventions
- guided imaginary
- relaxation
- distraction
- music
- cutaneous stimulation
- herbals
- reducing pain perception and reception
guided imagery
reduces the pts affective and cognitive pain perception
relaxation
allows the pts mental and physical freedom and develop sense of control
distraction
strategies that allow the pt to ignore or become less aware of pain
music
useful in treating acute or chronic pain, stress, anxiety and depression
cutaneous stimulation
stimulation of the skin through massage, warm bath, cold application, or transcutaneous electrical nerve stimulation (TENS)
herbals
- Important to ask the patient about ALL substances they take to relieve pain
- Supplements can interact with prescribed analgesics
reducing pain perception and reception
Remove or prevent painful stimuli
Control painful stimuli in patient’s environment by:
- Tightening and smoothing wrinkled bed linen
- Repositioning to relieve pressure points
- Adjusting to avoid laying on the tubing
- Changing wet or soiled dressings
- Lifting patient (not pulling)
- Avoiding skin exposure to irritants
- Prevent constipation with fluids, diet, and ambulation
Keys to success of pain management is
-An ongoing pain assessment
-An ongoing evaluation of the efficacy of interventions: (Does the patient feel relief?
Any side effects from the given medications? What is the therapy that works best for the patient? )
Pharmacological pain therapies
The “ideal” analgesic that is highly effective without significant side effects does not exist yet.
Analgesics
The most common and effective pain management method
Three types of analgesics
- non-opioids
- opioids (narcotics)
- adjuvants (co-analgesics)
Non-opioids
- Acetaminophen
2. Non-steroidal anti-inflammatory drugs
Acetaminophen major side effect
hepatotoxicity
Non-steroidal anti-inflammatory drugs major side effect
gastrointestinal bleed and renal insufficiency
opioids (narcotics)
morphine, hydromorphone, fentanyl, oxycodone
Major side effects of opioids
constipation, central nervous system changes, respiratory and cardiac depression
Adjuvants (co-analgesics)
Variety of medications that enhance analgesics
Multimodal analgesia
- Combines drugs with at least two different mechanism of action so the pain control can be more efficient
- Medications target different sites in the peripheral and central pain pathways
- The allow for lower-than usual doses of multiple medications (Lower risk for side effects)
Patient-Controlled Analgesia (PCA)
- Helps to achieve better pain control by self-administration of opioids
- Maintains constant blood level of opioids
- Minimal risk of overdose
How is Patient-Controlled Analgesia (PCA) delivered?
by pushing a button and deliver a specific dose of opioid, which is pre-programmed
- Patient teaching is critical to the safe and effective use
- Family members cannot push the button for the patient
Topical Analgesics
Over the counter creams, ointments, and patches applied to the painful area
local anesthesia
Infiltration of anesthetic medication to induce loss of sensation to body part by inhibiting nerve conduction
Perineural local anesthetic infusion
- Surgeon places the tip of unsutured catheter near nerves and the catheter exits from surgical wound
- Usually placed for 48 hours
- Sometimes left in after discharge
ex) on-Q pump
Epidural analgesia
- Opioids as single agents or in combination with local anesthetic is administered into epidural space
- Treats acute pain
- Less adverse effects compared to general anesthesia
Epidural Analgesia is inserted with
Inserted with a needle into particular vertebrae requiring analgesia
Nursing implications for local and regional anesthesia
- Provide emotional support during anesthesia insertion
- Motor and autonomic function (bowel and bladder control) may be temporarily lost
- Reassure pt that numbness, tingling, and coldness are common
- Protect pt from injury until full sensory and motor functions return
- Assess for symptoms of infection at the insertion site
Cancer Pain
- Can be chronic or acute
- Choose interventions based on pt’s condition and characteristics of pain change
Breakthrough pain
Transient worsening of the pain:
Incident pain
End-of-dose failure pain
Spontaneous pain
Barriers to effective pain management
- physical dependence
- addiction
- drug tolerance
Physical dependence
withdrawal symptoms after abrupt cessation of opioid drug
Addiction
- Disease with genetic, psychosocial, and environmental factors
- Impaired control over drug use, compulsive use, and continued use despite the harm
Drug Tolerance
Getting used to the drug; no longer benefiting from the drug’s one or more effects
Evaluation
- Reassess signs and symptoms of pt’s pain response including the severity, character, and pt’s self report
- Evaluate the family’s observation of patient’s response to therapies if applicable
- Evaluate impact of pain on physical and social functioning
Evaluating impact of pain on physical and social functioning
- If the intervention is successful, encourage the pt in self-care activities
- If the intervention is not successful, stop immediately and look for alternatives (Time and patience are necessary to evaluate the maximum effect)
